Provider Demographics
NPI:1861817264
Name:HEIDTKE, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HEIDTKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 GENERAL STILLWELL DR
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-6242
Mailing Address - Country:US
Mailing Address - Phone:831-883-5720
Mailing Address - Fax:
Practice Address - Street 1:133 GENERAL STILLWELL DR
Practice Address - Street 2:
Practice Address - City:MARINA
Practice Address - State:CA
Practice Address - Zip Code:93933-6242
Practice Address - Country:US
Practice Address - Phone:831-883-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-22
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA69913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist